Provider Demographics
NPI:1154698892
Name:KINGDOM SOURCE, LLC
Entity type:Organization
Organization Name:KINGDOM SOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WINFORD
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:AMOS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LAC, CCS
Authorized Official - Phone:337-456-6166
Mailing Address - Street 1:3226 GRAND POINT HWY
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-6221
Mailing Address - Country:US
Mailing Address - Phone:337-456-6166
Mailing Address - Fax:337-456-4830
Practice Address - Street 1:2506 JOHNSTON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3238
Practice Address - Country:US
Practice Address - Phone:337-456-6166
Practice Address - Fax:337-456-4830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-23
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty